NACHC is pleased to share our draft comments on the recent CMS proposed rule on Medicaid managed care. This rule is the first time since 2002 that CMS has proposed to update the rules governing Medicaid Managed Care Organizations (MCOs.) As such, it touches on a broad range of issues of direct relevance to health centers and their patients, including but not limited to:

Before submitting these comments to CMS, we welcome your comments on our draft. To ensure NACHC has adequate time to consider your input, please send any feedback to Colleen Meiman (cmeiman@nachc.org), Director of Regulatory Affairs, by Monday July 20.

**Note that the 3-4 highlighted items indicate areas where we are still seeking information ad/or finalizing our recommendations.

In addition, we strongly encourage your organization to submit your own comments on this proposed regulation. Please feel free to adapt or copy the language included in NACHC’s comments to suit your needs; we also encourage you to add examples based on your own experiences. Note that your comments must be submitted no later than 5 p.m. ET on July 27. You can submit them electronically by following the “Submit a comment” instructions at http://www.regulations.gov.

If you have any further questions, please contact Colleen Meiman, Director of Regulatory Affairs at cmeiman@nachc.org.

The King v. Burwell Supreme Court decision on Thursday marked a huge victory for ACA proponents. In a 6 -3 ruling, SCOTUS upheld health insurance premiums for eligible individuals in all states—regardless of whether their marketplaces were state or federally-established. The decision was met with both relief and applause by President Obama’s administration. With Congress still without a contingency plan as of Thursday morning, the ruling in favor of Burwell likely saved policymakers from months of legislative chaos, while also preserving health insurance for over 6 million Americans.

With the wait finally over, we are now left to consider what the Court’s recent decision means for the ACA moving forward. This is the last in a series of posts that have examined the case’s details and possible implications leading up to last Thursday’s big decision.

Breaking down the majority opinion

Chief Justice Roberts, joined by Justices Kennedy, Breyer, Ginsburg, Kagan, and Sotomayor, read the opinion confirming the legality of health insurance subsidies across all 50 states. Prior to the decision, many believed the ruling would be decided on the Chevron rule—or namely whether the federal agency (IRS in this case) had made a reasonable interpretation of the statute at hand. Instead, the Court announced the IRS was no health insurance expert and the Court, rather than the IRS, should determine the “correct reading” of the law.

The Court concluded the phrase underlying the whole case, “established by a state,” was indeed ambiguous. However, when read in relation to the ACA as a whole, the Court determined the underlying purpose of the law relied too heavily on the availability of subsidies across all marketplaces for “marketplaces” to be interpreted as solely those “established by a state.” In the majority’s opinion, limiting subsidies to only state-established marketplaces would undermine the entire healthcare system—something Congress would never have intended to do. Chief Justice Roberts synthesized these ideas in his concluding statement:

Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them. If at all possible, we must interpret the Act in a way that is consistent with the former, and avoids the latter.

Understanding the dissent

In a heated dissent, Justice Scalia, on behalf of himself, Justice Thomas, and Justice Alito, declared the Court’s majority decision as “interpretive jiggery-pokery” that omits the plain meaning interpretation of “established by a state.” Justice Scalia accuses the majority of once again rewriting the ACA to save it from its demise. As stated by Justice Scalia, the “opinion changes the usual rules of statutory interpretation for the sake of the Affordable Care Act. That, alas, is not a novelty.”

The dissent goes on to dismiss each of the points presented in the majority opinion; however, the opinions of Justice Scalia are perhaps best be summed up by his new nickname for the ACA: “SCOTUScare.”

What’s next for the ACA?

While the King v. Burwell ruling does not safeguard the ACA from additional legal attacks, it sets the precedent that the ACA is here to stay—at least through the end of President Obama’s second term. The ruling supports Congress’s intent to improve, not hurt, insurance marketplaces with the ACA—making similar court litigation unlikely in the future.

Although some fear the decision for Burwell may discourage states from establishing their own State-based marketplaces, HHS Secretary Burwell has vowed to continue to offer assistance to states wishing to shift towards a State-based marketplace. Burwell admits the administration still “has work to do” to make the ACA better, but remains optimistic on the administration’s chance to “build on the progress” the ACA has made. Following the decision, Burwell announced several new campaigns to improve the law, including a push to expand Medicaid in non-expansion states and reforms to payment systems to reflect quality not quantity of care.

Though the complete repeal of the ACA is unlikely at this point, the topic is almost guaranteed to resurface during the 2016 presidential campaign season. Although the ACA could take a beating during the upcoming race, President Obama remains confident in the future of his signature legislation. In a press conference on Thursday, President Obama heralded the decision remarking that “after nearly a century of talk, decades of trying, a year of bipartisan debate, we finally declared that in America, health care is not a privilege for a few but a right for all.” In his own words, it is becoming increasing clearer that “the Affordable Care Act is here to stay.”

We wanted to let you know about several rules that NACHC is currently reviewing with upcoming comment deadlines. Please be on the lookout for more information on our draft comments as the comment deadlines approach.

CMS Notice for Comment on the new Essential Community Provider Petition Process (comments due at www.regulations.gov by August 4, 2015)

As always, we encourage you to review these rules and our draft comments and submit comments reflecting your state or local experience. Please feel free to contact Colleen Meiman and Susan Sumrell should you have any questions about these rules or any other issues for the Regulatory Affairs Department.

Last week CMS issued its final rule on the Medicare Shared Savings Program and Accountable Organizations (ACOs). This rule encompasses a number of important changes for the Medicare ACO program, which you can read about in the final rule and fact sheet. While we are still going through the rule more thoroughly, we wanted to let you know about several health center specific issues that were addressed. You may remember that NACHC submitted comments on this proposed rule. Specifically NACHC’s comments focused on the following areas:

Supporting the proposed rule that would allow primary care visits from non-physician providers (NPs, PAs, and CNSs) to count earlier in the beneficiary assignment process for FQHCs

Requesting that primary care visits with only non-physician providers be considered “assignable” to ACOs

Requesting that CMS maintain the requirement that 75 percent of the ACO board members be providers.

NACHC was pleased to see that CMS accepted many of our comments in the final rule, allowing for non-physician providers to count earlier in the beneficiary assignment process and maintaining the 75 percent requirement that board members be providers.

ACOs play an important role in improving care coordination, and we were pleased to see these important changes for health centers. We believe that these changes will help to encourage more health center participation in ACOs and will continue to review the rule and update you on any additional issues that are relevant to health centers’ participation.

We wanted to let you know about several rules that NACHC is currently reviewing with upcoming comment deadlines. Please be on the lookout for more information on our draft comments as the comment deadlines approach.

Department of Veterans’ Affairs Interim Final Rule on 40 mile driving distance calculation (comments due at www.regulations.gov by May 26, 2015)

CMS’ Proposed Rule on Stage 3 Meaningful Use, the Office of the National Coordinator’s Proposed Rule on certification criteria, and CMS’ Proposed Rule aligning meaningful use (comments due at www.regulations.gov by May 29, 2015 and June 15, 2015)

CMS’ Proposed Rule on mental health parity in Medicaid managed care and CHIP (comments due at www.regulations.gov by June 9, 2015).

As always, we encourage you to review these rules and our draft comments and submit comments reflecting your state or local experience. Please feel free to contact Colleen Meiman and Susan Sumrell should you have any questions about these rules or any other issues for the Regulatory Affairs Department.